Tuesday, June 16, 2009

An Open Letter To Patients Regarding Health Reform

Dear Mr. and Ms. Patient,

It has come to my attention that in order for you to enjoy success as patients in the new era of health care reform, you must start working now to prevent illnesses that might befall you. Do not, under any circumstances, eat or drink too much. Fast food might as well be considered illegal. Exercise three, four, five times a day, even if it means take time off from work. It goes without saying that you should not smoke. The government has data that demonstrates how you have become fat, lazy, and a huge burden on our health care system. Your non-compliance threatens the very fiber of our economy. Even employers realize this, and are using calculators to figure your financial burden to them.

Now, in the unfortunate circumstance where you might become sick, you will need to develop symptoms that follow a few simple rules. Do not, under any circumstances, develop symptoms that fall outside federal protocols developed based on comparative effectiveness research data. If you do, your doctors will face pay cuts, litigation, limited resources due to lack of funding for cost-ineffective technologies, and the scourge of discharge planners. Does the term "leper colony" mean anything to you?

Rest assured, if you fall into one of the areas studied under the guise of comparative effectiveness research and I apply all of the 153 quality care measures deemed necessary, according to the President I will not receive a cut in pay and you will receive exemplary care. Further, my nurse coordinator will be more than happy to answer your calls, see you in the hospital, answer all your questions and service your symptoms. After all, Mr. Peter F. Orszag, an economist and Director of the Congressional Budget Office feels they are equivalent to my specialist care and will serve as "productivity enhancements," saving $110 billion. See how patriotic you'll be?

Also, do not be a surgical case that has any risk of failure. After all, "Complicated Patient" is the new scarlet letter as we work to cut even more costs. Fortunately, thanks to the new multitudes of guidelines for care that we must follow, I will be carefully interviewing you to assure that you fit into one of several pre-determined renumeration bins called "bundles." Please don't confuse me with more than one major disease since there is currently no way to handle this circumstance. I would suggest you pick the disease that bothers you most.

Unfortunately, after years of clinical practice I have observed several clever patient stunts, like failure to respond to medications, unusual unforeseen infections, having an rare disease, and the like. I strongly recommend against these shenanigans as we move forward. It is in your best interest to not require long hospital stays, dear patient, or else.

I wish you the best as we move forward in this exciting time. Please feel free to contact my automated pool of nurse coordinators if you have questions. They'll each open your message, play a little "hot potato" with each other, and then contact you as our information technology system streamlines communication.

57 comments:

Daniel
said...

My how clever you are! But you don't seem to be aware that the US health care system is overpriced. The consumer doesn't get the quality of care that he or she pays for. Putting the system in the hands of people like you does not work. The M.D.s had their chance and they blew it. Just like the Merrill Lynch execs who cared more about their bonuses than the US economy, M.D.s seem blind to the big picture.

Daniel, I totally agree. We doctors order too many tests, and perform too many procedures. After all, the government says so. And no one has a better grasp of the big picture than the government.

So. Which tests and procedures would you like me to stop doing? The CT scan of your abdomen after you've been in a car accident? The c-spine films prior to surgery in a rheumatoid? The third set of enzymes in your workup to rule out a myocardial infarction? The Pap smear in your 20-year-old daughter?

Y'know, I generally agree with your point here, but I wonder, are insurance companies really so much better than the government? Are you implying that the privately purchased insurance is wholly without limitations? or financial incentives?

I guess my ultimate question is, what is the solution? Health care is really expensive right now, if you have insurance, you pay through the nose and they still wont cover certain things. If you don't have insurance everything is prohibitively expensive.

What is the solution? I mean, I don't want government funded health care, I really don't. But I WOULD like people I know with pre-existing conditions to be able to get some kind of care within a reasonable price range.

It's one thing to oppose proposed solutions, but to do so without proposing an alternative leaves everyone high and dry. (Unless you think there is no problem with the current system, which is also worth discussing.)

What is the solution? I mean, I don't want government funded health care, I really don't. But I WOULD like people I know with pre-existing conditions to be able to get some kind of care within a reasonable price range.

Shinobi-

Your comment is one not easily solved, given the multitude of special interests that have interjected themselves between the doctor/patient relationship. There have been MANY solutions proposed (here's one, for instance for primary care). Personally, I DO believe we have no choice but rationing of health services we provide. Doctors,in concert with their patients and families, should be the ones' deciding about such issues as futile care, unnecessary testing, and the like. But the lack of tort reform binds us to persisting in our current ways of "cover-your-ass" medicine. Certainly, the fee-for-service model needs reworking and there are people in America who need health care that are not able to afford it. But government's inability to clarify where the money goes (and why) clouds meaningful discussion of where we should focus our limited resources.

To suggest that these complicated issues must be solved before the end of this year's legislative session only heightens my suspicion that back-room deals are in the works favoring certain well-connected members of our health care reform team. Patients do not understand what's being proposed as a means of rationing care, government-style, with limitless bureaucracy, rule-chasing, and an entitlement attitude (hence the pupose of this post). But this is what Americans want - no overt rationing, but rather government developed strategies to do the same thing in clandestine, almost sinister, ways.

But better to not think about what's being said on the Hill, right? Let's applaud the actions taken! Let's not care what this will cost each of us! Let's just provide health care for all and not be prepared to live with the consequences of a fiscally impossible solution to our current crisis and for God sake, make sure we vote on it before our fall recess.

I'm curious to know your views on tort reform - specifically, your position on proveable medical malpractice. While I agree that some reworking of the current system is needed and necessary, absent some type of peer review (with consequences) what, exactly, is the recourse for the patient and/or family who is on the receiving end when things have a bad result as a result of poor medical care and treatment? I don't mean to speak in such broad terms regarding your profession - but you must acknowledge that there are 'less than competent' professionals in the medical field and yes, they cause harm.

Found your blog through a link on the Cover Rationing Blog. Great post! I'm a primary care MD who is sick and tired of being expected to be surrogate nanny for patients who won't take responsibility for thier lifestyles.

DrWes, I'm really scared about what health care is going to be like this time next year. I'm in my late 20's and am currently testing for a condition called Cushing's Disease. It's been a nightmare dealing with my insurance company, but without insurance (which my parents can afford for me thank God), there's no way I could have started this process in the first place. One visit to my doctor, coupled with one test, is $10,000. Oh but Medicaid would pay for all my testing and surgery, after all I'm low income so I should just quit my insurance and sign up for Medicaid, right? Yeah right. To be blunt, my care is too expensive for a government program, not to mention that surgery is the only treatment for this disease. Already I would be considered a drain on our limited government-funded medical resource programs, leaving me with no options to cure my illness which is fatal if left untreated. I want all of your readers who are so incredibly high and mighty about criticizing our current structure to think about someone like me, a healthy young woman except for one incredibly expensive disease that no wellness program or preventive method could have foreseen or stopped. People like me are going to be the ones most negatively effected by these changes, not all of you who complain so much about the cost of health care but who don't actually have to use it beyond the annual pap smear or flu shot.

The reason why health care is so expensive is because of government programs such as Medicare and Medicaid and laws which drive the cost up (such as the law that hospitals have to treat everyone free of charge in the emergency room). The solution is to get government interference out of health care and get back to the free market system we had in this country more than 100 years ago.

Socialized medicine is immoral because it enslaves doctors. this quote says it all: “I have often wondered at the smugness with which people assert their right to enslave me, to control my work, to force my will, to violate my conscience, to stifle my mind -- yet what is it that they expect to depend on, when they lie on an operating table under my hands? … Let them discover the kind of doctors that their system will now produce. Let them discover, in their operating rooms and hospital wards that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents it -- and still less safe, if he is the sort who doesn't." -- Dr. Hendricks in Ayn Rand's Atlas Shrugged.

"I quit when medicine was placed under State control, some years ago," said Dr. Hendricks. "Do you know what it takes to perform a brain operation? Do you know the kind of skill it demands, and the years of passionate, merciless, excruciating devotion that go to acquire that skill? That was what I would not place at the disposal of men whose sole qualification to rule me was their capacity to spout the fraudulent generalities that got them elected to the privilege of enforcing their wishes at the point of a gun. I would not let them dictate the purpose for which my years of study had been spent, or the conditions of my work, or my choice of patients, or the amount of my reward.

"I observed that in all the discussions that preceded the enslavement of medicine, men discussed everything—except the desires of the doctors. Men considered only the 'welfare' of the patients, with no thought for those who were to provide it. That a doctor should have any right, desire or choice in the matter, was regarded as irrelevant selfishness; his is not to choose, they said, only 'to serve.' That a man who's willing to work under compulsion is too dangerous a brute to entrust with a job in the stockyards—never occurred to those who proposed to help the sick by making life impossible for the healthy. I have often wondered at the smugness with which people assert their right to enslave me, to control my work, to force my will, to violate my conscience, to stifle my mind—yet what is it that they expect to depend on, when they lie on an operating table under my hands?

"Their moral code has taught them to believe that it is safe to rely on the virtue of their victims. Well, that is the virtue I have withdrawn. Let them discover the kind of doctors that their system will now produce. Let them discover, in their operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents it—and still less safe, if he is the sort who doesn't."

Now me, I don't go to the doctor for symptom suppression. I go for diagnostics.

I recently went to the VA Hospital (I'm entitled as a vet) for bloodwork. I informed the nurse ordering the work that I wanted any test that would give me an indication of my nutritional status. I had to specifically ask for a test for vitamin D and a celiac panel. The nurse didn't even know what to call it. I guess she'd never ordered one before. We did the standard cholesterol screening.

I asked if there were other tests to determine mineral levels or anything else that I could treat nutritionally. Her response? "We can't just test for everything you want. These tests are expensive. But I'll set you up for a mammography and pap smear." I didn't ask for them, and I don't want them.

Here I am, a patient who is fully responsible for her own health and who never goes to doctors other than for occasional diagnostic work, and I can't get simple tests done because they might cost a few hundred dollars. And the nurse criticized me for not getting a mammography.

I made very clear to the nurse that my intent was to treat any deficiency nutritionally. The results came back with high cholesterol, and they immediately wanted to put me on a statin.

After asking several questions to get past pharmaceutical treatment, the nurse I spoke with finally told me how I could treat the problem nutritionally. It was like pulling teeth!

Until those in the medical field:

1. study health instead of pathology

2. truly empower their patients to take responsibility instead of the typical lip service

3. begin addressing cause and not suppressing symptoms

4. offer first behavioral modification instead of pharmaceutical intervention (and avoid the typical copout: "People don't want to change. They want us to fix it all."

5. learn something--ANYTHING--about nutrition

then the system will perpetuate disease and build an ever-larger customer base of people pouring their wealth down the drain while their health continues to deterioriate until they take their last breath trapped in a hospital bed.

And while I'm at it, the patients need to stop running to doctors for every little thing, get off their butts and move around and read a book on health and nutrition once in a while.

This is from someone with arthritis in both knees whom doctors told would end up in a wheelchair. My body healed itself after a month-long regimen of nutritional supplementation. That's something few doctors would ever prescribe. But they would have enjoyed cutting out my kneecaps, I'm sure.

My father was a doctor; In the late 1940s he was also a co-founder of a large medical co-op in downtown L.A. A family paid an annual membership fee ($25 in 1947) and then paid $1.25 per visit. The co-op had every kind of specialist, test. lab, all in the same building. If your personal GP (you had your own;it wasn;'t a clinic) believed you should see a specialist, another buck-and-a-quarter. Have an xray, same price. At the end you went down to the basement with your prescription and got it filled at cost.

There was no discrimination for "pre-existing conditions." My father's group would have treated the woman who's got Cushing's.

Still seems to me like an interesting solution to current problems. Pay the "premiums" directly to the people who do the work and who use their medical judgment. Not to either bottom-line insurance company bureaucrats or, worse, government ghouls.

Char, I think you should look at some literature that actually analyzes our system versus others around the world to see where we are spending far too much money. Ignorance piggy-backing on idealistic faith is a pretty mean combination.

The McKinsey report is excellent, maybe the most detailed breakdown of cost/benefit that has been done for any health care system.

Google this DOI for another good report on standard of care across 18 nations: 10.1377/hlthaff.27.1.58

If you would like to stop treating people who walk into clinics as well you'll need to get rid of most of the physicians and start over, there are traits that make you a good physician and its no coincidence that empathy and the urge to help are two of the most highly regarded.

Having grown up in a family full of doctors I share so many of your concerns regarding CER. That said, I do disagree with the idea that CER can only end with a treatment CZAR who dictates medical care by fiat. I realize we're getting new "Czars" every day, but it's possible that CER could be used to help patient outcomes and personalized medicine. I wrote a longer post on this debate at http://newvoicesforresearch.blogspot.com/2009/06/cers-definitive-maybe.html

Thanks for the great post. Agree or disagree no one can say it wasn't funny.

Grace DeCicco said, “There is one element missing from the government's scheme which no one seems to address. That is the right of the doctor. And, it is only through their sanction that this proposal can be passed; what Ayn Rand called, "the sanction of the victim." If socialized medicine in passed in this country, you will see the best of the medical field "Going Galt."

We need to reach doctors with a message that they need to speak up for their rights. This is a life and death issue literally! Here are some links to articles that provide fuel for doctors to defend themselves: Health Care is Not a Right: http://www.capmag.com/article.asp?ID=5123 and Take a Stand for the Rights of Physicians: http://www.capmag.com/article.asp?ID=4930. For more information, please see these web sites: Americans for Free Choice in Medicine: http://www.afcm.org/ and Freedom and Individual Rights in Medicine: http://www.westandfirm.org/.

I came over here from Sandy's blog as I have a lot of respect for her work. However, my reaction to your post is, "Good! That's the way it should be." The fundamental problem is not the AMA. It's medical ethics that promote a vision of endless life and endless well being. I'm sorry, life sucks. Then you die. And people who pay for doctors are paying for an illusion.

I came over here from another site because the introduction looked intriging. I suppose I was expecting a wry mockery of the pros and cons. The one sided nature of your mock letter makes me want to say of doctors, "They just don't get it." Our system is broken. Why don't doctors participate in helping us fix it?

When doctors write criticisms of health care reform because they care about nothing but their money, why should I care about doctors. You don't like the government interfering in health care? How about we make it leagal for anyone to prescribe?

Frankly I don't know how primary care docs who are not hospital employees keep their doors open. Who among you would spend 8 years in school (after HS) and 3-5 years more in training after that for $150K a year? Make no mistake: in your old age you will be treated by a physician assistant or a nurse who chooses your plan of care from a government provided checklist based on the comparative effectiveness formula. You think it's expensive now, just wait until it's free. What makes everyone think they are entitled to something for nothing? Medicare and Medicaid recipients who already get something for nothing, that's who!1. Tort reform2. Strict illegal immigration enforcement3. End of life care rationing. For folks who want "all the stops" pulled, they must pay for it themselves.4. Americans should stop subsidizing pharmaceutical R&D for every other 2nd world nation.How's that for reform?

Frankly I don't know how primary care docs who are not hospital employees keep their doors open. Who among you would spend 8 years in school (after HS) and 3-5 years more in training after that for $150K a year? Make no mistake: in your old age you will be treated by a physician assistant or a nurse who chooses your plan of care from a government provided checklist based on the comparative effectiveness formula. You think it's expensive now, just wait until it's free. What makes everyone think they are entitled to something for nothing? Medicare and Medicaid recipients who already get something for nothing, that's who!1. Tort reform2. Strict illegal immigration enforcement3. End of life care rationing. For folks who want "all the stops" pulled, they must pay for it themselves.4. Americans should stop subsidizing pharmaceutical R&D for every other 2nd world nation.How's that for reform?

Well done! Courtesy of your tax dollar at work, I have lived overseas since 1983 except for short periods for home leave and visits. Those who complain about American health care ought to visit hospitals and clinics in the countries where I have lived. No health care system is perfect, but I have received outstanding care in the USA when needed. It is time for reality check for many: we are designed to get old, sick and die. Sorry, no doctor can stop that. Want to reduce health care costs in the US? Then end the outrageous law suits!

Those programs have provided care to millions. They are't appreciated by the majority of doctors because you can't afford a Jaguar or a Bentley on MediCare/MediCaid reimbursement (unless, like so many "medical professionals," you commit fraud).

I have insurance and good doctors and if I could throw a switch and create a single-payer system in the US, I wouldn't hesitate.

Judging from your flippant attitude, you are one of the system's problems: You think a medical degree is supposed to be a guarantee of wealth. Maybe you should get out of medicine and manage a hedge fund since you are willing to gamble with your patients' future -- that they won't lose their jobs or be denied coverage for some bogus reason -- against you getting your payment from the insurance company.

Doctors and private insurors in the US are co-conspirators in the biggest extortion scheme in history.

Everyone wants to talk about the superior quality of the U.S. system but the numbers don't bear it out. And the best system in the world is pretty bad when your primary care physician is an emergency room doctor.

..."Jaguar"..."Bentley"..."you commit fraud...Doctors and private insurors in the US are co-conspirators in the biggest extortion scheme in history."

Abraxas-

Wow. Please get your facts straight. For the record, I served in the United States Navy for 13.5 years as an active duty medical officer and completed over 26 years of service in our government health care system before retiring from the US Naval Reserves. I left the service because I was underpaid relative to the private market. I do not own a Bentley, Jaguar, and am a salaried employee of our health care system (yes, I do receive "productivity" bonuses when I work extra-hard). My salary, as such, is determined by market forces and not is not part of any "insurance" conspiracy, other than that imposed by the bureaucratic requirements of Medicare and Medicaid, of who 85% of my patients are covered by.

And yes, Medicare's trust fund is set to become insolvent "somewhere between 2016 and 2018." Wy doesn't the government fix Medicare's problems first, rather than imposing whole new unproven entitlements for which they have not determined a way to fund?

As a person raising a family without access to medical care, I can't get excited about horror stories about changes in mode of service for those who already have access. Fifty million of us are just invisible in discussions like these - and no, there aren't fifty million illegal aliens or invincible twenty-somethings who "choose" not to buy insurance. My husband and I both suffer from chronic illnesses caused by genetics, not lifestyle. I sell a bit of stuff on ebay while homeschooling the kid and he is a self-employed IT professional. Although his skills are top-notch, he is physically unable to cope with the rigors of 9 to 5, as am I. No matter how hard he works in any given year, health insurance is out of the question. For several years his income briefly tipped into the six-digit range, and we spent it all racing to make up for years of economically-enforced medical neglect, while maintaining a *barely* working-class lifestyle. The standard of care for our conditions adds up to about $50,000/year. Every month is a balancing act between the bare minimum level of care necessary for my husband to keep working, and all our other needs.

Oh, and our 3 year old has a pre-cancerous mole on her foot which we are currently SAVING to have removed by cutting back on an already tight grocery budget. We will never accumulate any real, long-term savings, though, because our skills and vocations simply do not afford the income potential to ever get ahead of medical costs. (And is that really so shocking? Except for the truly wealthy, almost no individual in our society earns enough to cover chronic or catastrophic medical expenses. Certainly not the middle-class Randites, so proud that they've got theirs, oblivious that they would probably be as unprotected as I am without the subsidy from my family's self-employment taxes.)

Dental is out of the question. Eyeglasses last four or five years instead of the recommended two. And so on.

What I take away from blogs like this is that you don't care about people like me, or prefer to pretend that we don't exist, or regard us as somebody else's problem. That Ayn Rand gets mentioned in all seriousness speaks volumes: if you don't have, it must be because you don't deserve. People like me and my husband are Randian "looters" and "moochers," despite our herculean efforts to maintain a semblance of productive household life rather than collapsing into SSI dependency, as many (especially doctors) have recommended that we do.

Well, I read Ayn Rand once too. IN HIGH SCHOOL. It's adolescent literature for a self-indulgent adolescent worldview. It turns out that philosophy and economics is a lot more complicated than she would have it. I recommend John Rawls to start.

In a universe of finite resources, some form of rationing is inevitable. It's theoretically possible to make a case for rationing on the basis of ability to pay (notwithstanding that the winners and losers in a true ability-to-pay system would be significantly, perhaps surprisingly different than in the current tax-subsidized [and how Randian is that?] corporate-employment-based system). But I don't see that argument being made anywhere, because it's a morally ugly argument, to the necessary premises of which nobody but Randroids can assent. Instead we get a bunch of flim-flammy, obscurantist substitutes for that argument, all of which depend on implicitly pretending that people like me don't exist, but that if we do, we must be doing something wrong to deserve our fate.

If you really believe that the rich and fortunate deserve to prosper and the poor and unlucky deserve to die, claim it. Take responsibility for the moral costs of the status quo which you are promoting.

EMG, Sorry to hear about you life situation,and if you were a family member or friend of mine I would be moved to help you.... That said, how do you conclude that your want entitles you to demand a portion of my life? I doubt you would feel justified making that demand to me personally, but you appear to feel comfortable asking the government do so on your behalf, with the promise of violence if I dont comply.

Anonymous, I do feel quite justified in making the demand of you. While I'm not in the habit of begging, I would do it if I had to, and I absolutely believe that a poor person's plea for the necessities of life are morally binding on the rich. The distinction about whether I would do it "personally" is a red herring. Government is the mechanism we use to enforce social norms and obligations. How much that should overlap with "morality" in the sense I am referencing is a very open political question. But it seems clear that your preferred answer - that it do so not at all - was already taken off the table a long, long time ago, with no hope of a comeback. You might want to think about why that is.

Have you read Nozick? Nozick has what seems like a really elegant argument for radical libertarianism, but even he admits that one of his key premises is seriously flawed. Namely the assumption that the original distribution of goods was just. Even in the short history of our own country we can see how ridiculous this is: huge amounts of land, labor, and resources were taken at the point of a gun. Women and blacks were forbidden by law (and the threat of force!) to seek education, enter the professions, have a voice in the political process. Mexicans lost a huge amount of national territory at the point of a gun and now can only inhabit it "illegally". Etc. Your (and my) present condition is largely due to having been born, through no merit of our own, on the right side of a long string of such violent encounters.

It might even be argued that it is you who are taking a piece of my life, hypothetically speaking. If the labor of the poor were priced high enough to cover their medical needs, the buying power of your own income would be much lower. (Only in this case it really is their *life* and not merely their property, for they are frittering their bodily health away in order to fry your burgers and sew your clothes.) Given that the present price structure of health care (and everything else) is already the product of government regulation, you can't claim that this is a just or natural libertarian outcome. And - as I stated in my last comment - unless you are an unusually rich or talented person, you have no reason to think that ideal libertarian reforms would favor you.

I also don't believe you when you say you (are willing to) give private charity. The only reason you frame taxation as involving "the threat of force" is because you contemplate resisting. And why would you resist, other than that you don't want to give? It can't be because of a philosophical objection to the threat of enforcement, although I'm sure you tell yourself that's what it is. The threat of enforcement is moot unless you really really _want_ to resist the thing itself. The reason I don't sit around fuming about the state's use of force to keep me from killing people isn't that I was philosophically convinced of the state's right to make such a law - it's because I have no interest in killing people. Only a person with an unusually strong aversion to giving as such would think anything but "here's a way I can give (however imperfectly) *and* avoid state-sponsored violence! Two birds, one stone!"

I came across an interesting read recently on healthcare accessibility issues. How to de we provide quality healthcare to all our people? This is a question with no precise answers as of now.This article talks about the role of online healthcare.

Thank you, Dr. Wes! I love it...I've been sharing this with so many people. For several years after I graduated college, I did not carry insurance, and always knew I was rolling the dice. Fortunately, nothing major happened to me, but I fully accepted the fact that it could at anytime, and I knew the consequences of that decision...my savings would be GONE.

I know own my own company which provides excellent coverage for me and my partners, and quite frankly, I'm PROUD of the fact that I've built an opportunity for myself, to take care of myself.

I have very little sympathy for those who choose to roll the dice and still carry this 'well, what about me?' attitude. There are plenty of policies out there for those types that are more affordable and offer major medical coverage.

Now, in the case of Mrs. EMG, and those like her who have chronic illnesses, something must be done. I don't think the Universal Healthcare System is the answer, because people like EMG are the exception, not the rule.

How in the world, then, do we let people like myself who enjoy their coverage, keep it IN TACT, but still find ways to take care of the EXCEPTIONS?? Why can't the government leave the rest of us to our own devices and start some sort of healthcare fund just for those rejected by insurance carriers due to their conditions?

Am I naive? Is this something that could be possible? It does seem a shame that people like EMG have to go through such struggles.

Dr. Wes--Loved the post, frustrated at some of the comments. What I see reflected is a fair amount of entitlement. We have created a system where patients (see EMG and Joanne) feel that because they are disabled/ill they do not have a responsiblity to manage their care and their lives. Instead, we as physicians are responsible, no, required, to care for all their needs, while they "sell a bit of stuff on ebay and home school their children." EMG, take responsibility for your life, and your family. Get a job, and become an adult. I as a physician can manage your disease, but not your life. Entitlement got us here, not "greedy physicians." (PS: Abraxas: I drive a subaru with 200,000 miles on it. Isn't a jaguar an animal?!)

Dr. Lisa said: Who among you would spend 8 years in school (after HS) and 3-5 years more in training after that for $150K a year?

Gee, I spent nearly that much time in school (yes, after HS, too) and I don't get paid anywhere near that. How horribly sad for you that you are paid a mere $150K/yr.(/snark)

While I'm being deliberately mean above, I am totally serious about the facts. I make considerably less and live quite comfortably. In fact, I feel very well paid compared to colleagues in similar fields, with similar educational backgrounds. So really, get over yourself. We have no sympathy for you based on pay. Administrative nonsense, yes; pay, no.

1. Malpractice suit results for every MD be posted publicly for inspection by any potential patient. Names of patients obfuscated.

2. Doctors charge what the market will bear for their services....based on their publicly records, the publicly available feedback of their patients, and their years in practice. Names of patients obfuscated.

3. Insurance premiums based on twice yearly physical health exams which include a battery of standard baseline tests, tracked over time, including treadmill workup, Lipids, full blood work tests, and specific gravity body fat percentage tracking.

In response to EMR and rationing.I think you are the most articulate and honest author I have read in regards to society's responsibility to the unfortunate. I agree with your statements but come to some different conclusion. First on charity, I think many people resent an outside force (the government) setting the priorities and rates for the charity (taxes) they give. And so I think it is truthful that someone who gives to the causes they value might feel forced to provide for the causes they don’t value. Personally I provide aid to people who suffer though no choice of their own. For those that choose to drink, eat, smoke, shoot up etc to excess, I believe that they have the right to make those choices and to experience the full consequences as well. As for the cost of health care for the average person being unaffordable, I think we need to clarify the meaning of health care. In a third world nation, the very best health care available might cost only a few dollars to provide and require only a nurse, a syringe and some antibiotics. But in the US the best care available might involve experts of several fields, high tech equipment costing tens of million of dollars, newly developed drugs that must provide a return on investment in only a few years, and payments for malpractice insurance that add 20% to the cost of everything. I think the average person, of average health, can afford to pay for an average level of care. It is only the extraordinary in terms of health events or individual disease that requires insurance and cost large sums.

The overall problem is one of limited resources as you say. And as you say we have as a society rejected the idea of letting the frail simply perish. I believe that is as it should be but what to do?

Abolish malpractice insurance and accept that people are imperfect as are all of the drugs and inventions of people. Set a realist expectation of what defines an acceptable level of perfection. So if 99.9% of the time a surgeon gets it right, then he keeps his medical license. If he drops below that threshold, then he loses his license. If a vaccine prevents disease 99.99% of the time but kills one in 10,000 then the drug is acceptable. No one can sue anyone who meets the thresholds. This does not prevent suing a surgeon who operates while drunk and kills someone. That is manslaughter not malpractice and should not be insurable against in any event.

Limit healthcare for people who make life style choices that negatively and strongly influence their health. All choices in life have consequences (good and bad) and we should not as a society provide insulation from those consequences.

Create a first class and second class health system. The only reason I can afford to fly cross country in coach is because of those folks paying 5 times as much in first class. First class heath care is expensive and should not be government subsidized in any way. First class health has access to every device, expert, medicine and technique available. The risk of first class health might be higher with new drugs and new techniques, but the rewards might be high as well.

Second class heath is affordable and subsidized but limited to the standard of care that would have been provided 10 years prior to today’s First Class health. So new non-generic drugs, newly invented machines or techniques would be unavailable. Second Class health would in essence be the equivalent of the healthcare provided by most of the rest of the world today.

I believe the health care plan by the big O stinks. If I wanted to live under socialism I c ould go to Canada or Great Britain. This great plan will benefit illegal aliens and some people without insurance. As I recall the Constitution it doesn't say we have a right to free insurance which will be paid for by the people who are rich. The plan sucks. I believe we need change starting with new people in Congress who are Americans and have some experience. The big O came out of Chicago where government has always been corrupt.

HOW do we fight this? The only organization I found specifically geared to fighting "reform" was Conservatives for [Thin] Patient's Rights, but they know nothing about fatness, are still clinging to the "overeating", "fatness is voluntary" myths and are perfectly willing to sell out middle class and poor fat people so long as thin people (and rich fat people) stay safe. I am specifically, literally terrified that I will end my life (I'm 50, now) as a murder victim, i.e. "euthanized" or denied ANY form of needed care because fat people (and any substantially disabled person, and anyone over 60) are going to be one of the primary scapegoats of this system. We'll not only be allowed to die before our time, but encourage to. The number of people who still cling to the myth that fatness is "caused by overeating" is TERRIFYING. How can an entire system of potentially deadly ideas be based on an absolute myth? HOW DO I FIGHT FOR MY LIFE?

When did it become OK to profit off of the sick? And why shouldn't healthcare be afforded to everyone? If our Congress members would get their heads out of their asses and look beyond our borders they could take the best of all the other countries and make it second to none. As is the way with Americans though, we want the easy way out. Oh, just keep it the same because I have good insurance. Is there really a lot of choice with BC/BS, Aetna, or United Healthcare - NO. Everybody has to wait and everyone who just loves their insurance is only one claim away from having it blow up and it will. The statistics are against them. I don't agree with Obama's plan - probably because it still remains a mystery but to have the profiteering insurance companies involved is ludicrous. Have we learned noting from the financial corps? And again, why are people making a profit from sick people? This is unethical and cruel. As an educated person I can't believe you even utter such nonsense about rationed care. Care is ALREADY rationed! Plus, clarifying an advanced directive with the elderly does not equal rationed care. Makes me scared that seemingly rational people can become so blind to what is being said. As for Medicare - I do believe most retired persons have PAID for that service already. I am just astonished at this (il)logic and you'd better hope you are never hit with a catastrophic illness as your "insurance" will fight to deny you coverage.

I'm an educator, underpaid, my pay is under goverment control, but every day I go to work and do the best I can give evrything I have to the goal. I suspect being a Doctor is the same way, we do it because we love it.

Everyone in America has a right to my services. This is true of Policemen and Firemen, and should also be true of Medicine.

Our education should be supplemented because we are giving ourselves, our lifes work, to a humanatarian cause.

The insurance company is the criminal in the current medical problem. Their greed is well documented and overt. They have no problem telling you that they will always deny payment the first request, and refuse anytime they can manufacture an excuse.

The current improvements do not remove them from the process, it only tries to impose a code of ethics upon them. The change is not bold enough, flawed by the largest policital slush fund and hoard of lobbist the United States has ever seen.

The English model of National healthcare gives the Doctors insentives for things like helping patients lose weight stop smoking get in better shape, preventive medicine.

There are 50 million working americans. My insurance cost me $400.00 a month, $200 would be reasonable. 50 million $200 X12 =paid to a non profit overseer called american health care should serve to start us down the right path.

The next problen is the drug cost in America are greater than the same drugs in other parts of the world. This is mostly due to insurance mark up to inflate profits.

I believe in America, I believe in Doctors, I believe the hearts of mankind is good. Capitalism can get out of control, and it has. by letting the Health Insurance Companies, who produce nothing but paperwork, become a part of our medical comunity.

If I ever have children I will tell them absolutely do not go into the medical field.

God, is this what I'm going to face when I become a doctor? Entitled SOBS at every stop. 200k in debt, most likely. Just starting out 10 years or more after my peers usually start their careers. All those years of lost income. Parasitic lawyers. Minimum wage residency. Just so someone can tell me, I'm a selfish SOB because I expect to be paid for my level of expertise. Oh and btw those residencies expect you to work 80 hours or longer a week. Do you whiners even know how much education it takes to become a primary care doctor let alone a specialist? This is why the US has the best doctors in the world. But I doubt that will last long. But to hell with it, let the NPs dish out primary care now since they are experts with those two extra years after BSN and thesis under their belt. I think it is absolutely shameful how much power is being extended to mid-level providers who have not gone through vigorous training. It is down right dangerous to send patients to these people.

Most of doctors I know come from middle income families. I can assure you that I am not rich and most likely will not be since I'm crazy enough to care about the primary care shortage in this country. God knows why. I see the way the wind is blowing with all these mid-level providers.

If I hear one more 'oh those lovely NPs spend so much more time with patients, they are soooo much better than doctors'...

I realize this blog is old, but I feel compelled to vent my outrage at many of the comments anyway.

Daniel - When you say that the consumer doesn't get what they pay for, I am curious to know exactly what you mean. If you imply that because our country's high spending with overall poorer health and longevity is because of our inadequate health care system - you would be very wrong.

When you compare the US to other countries, focusing on the huge differences between our spending, costs, and outcomes consider these HUGE differences too:

Obesity - Obesity requires a lot of expensive health care, when the "cure" lies more in the possession of the patient than the health care system. AND, despite that costly consumption, the health care system can do NOTHING to help you be more healthy or live longer while you CHOOSE to remain obese. All the health care system can do is help you with symptom management from your obesity.

Bottom line is that all of these things directly impact A. Spending, B. Cost, and/or C. health and longevity. Interestingly, these elements are not in the hands of the physicians.

It seems to me that the liberals in this country want taxpayers to foot the bill for their needs, be unhealthy and violent and impose the costs for those choices onto others, AND WORSE remain free to grab a good chunk of cash from the system by frivolously suing a provider for an unintended outcome

I used to consider myself a moderate liberal prior to this health care discussion, having not yet ever voted for a Republican - which is about to change dramatically!! I used to think the charge against liberals for being lazy whiners searching for handouts was unfair. After this discussion, however, I have seen the light.

First - Are you angry over all wealth, or just the wealth of physicians?

Perhaps we should do away with wealth altogether in this country? Because, certainly, if physicians whose career choices impose demands and requirements NOT MATCHED BY ANY OTHER CAREER CHOICE in this country cannot have access to the American dream of EARNING and ACHIEVING their way toward a wealthy lifestyle, then nobody should!!

When this country is no longer America, and is no longer the wealthiest nation in the world, and our youth no longer grow up surrounded by wealth and success - creating the desire to EARN and ACHIEVE the very success they see around them, then maybe people like you will be less bitter and feel a little happier living here. When dedication, achievement, skill and intellect are no longer rewarded - but handouts are much more the norm, maybe you will somehow feel more adequate with your own achievements, whatever they may or may not be.

In the meantime, please show me ONE physician who became as wealthy seeing patients as trial lawyers like John Edwards did suing doctors becoming a MEGA multi-millionaire off the health care system - all with less than HALF the time spent on their education, no on-call, no risk for lawsuit to provide their services, no life or death decision, no going in at 2am to open up a persons clogged artery to save them from a heart attack or stroke, no barrage of phone calls during the nights from nursing staff needing guidance on medication and treatment options.

Please show me ONE physician who became as wealthy seeing patients as the insurance and drug industry executives with their multi-million dollar bonuses - also with less requirements and sacrifices than the physician.

EMG - It seems to me your grievance should be about the pre-existing condition problem with health insurance. Based on your statement of income, it seems clear that you should be able to afford a health insurance policy, unless your priorities are not in order. I would agree with you that the pre-existing condition must change.

Many of the people I know make much less than that (including myself), and yet they make health insurance a priority. My niece and her husband are self employed, making just over 50k a year, and they purchase their own health insurance policies.

What does disturb me, however ,is the fact that you feel automatically ENTITLED, based on your status of uninsurable and the fact that you were born, to obtain the services of physicians, nurses, etc.

People who have government insurance policies only, ie., Medicare, Medicaid, SCHIP, are receiving their health care AT COST to the provider because the government reimburses below the costs to provide the care. This diminishes access for those people because providers cannot provide that service to very many people, and keep their doors open. So, they accept only a FEW of those patients, making up the costs through their privately insured patients. The Centers for Medicare and Medicaid Services (CMS) itself stated not long ago that between the years of 1992 and 2010 the inflation of costs to provide health care rose 54%, while physician reimbursements only rose 11%. Do you understand WHY doctors have trouble accepting anything but a very small number of those patients?

Moreover, on the one hand you want to sort of point your finger at greedy physicians unwilling to share their skills and talents with you at a price you are WILLING to afford - and perhaps for free (because, again, an income like yours should be able to afford a health insurance policy).

On the other hand, you yourself speak in a very greedy sense when you assume that you have some moral right to free access - or perhaps access at rates equal to or less than what it costs them to provide you the skills and services of physicians whose training required 11 to 15 extraordinarily demanding, expensive and personally sacrificing YEARS to achieve, AND puts them at huge legal risk when providing those services to you.

When our country changes our legal system, maybe our physicians and nurses will feel more charitable and inclined to provide their services to people like you for free.

I think the concept of a Health Court is worth exploring, the concern I have with the one described at commongood.org is that the range of remedies seems restricted.

When I was married my wife had a physician treat her in a way that I think should have resulted in his losing his license or being jailed for assault.

Briefly, she was spotting, saw her gyn, who couldn't find her IUD, so they took an ultrasound, and scheduled her for a laparoscopy six weeks hence. Six weeks pass, and the spotting resolves itself. She goes in for the laparoscopy and the surgeon can't find the IUD either, so he performs a laparotomy that she never consented to, and that she never would have consented to (we had gone to some pretty good lengths to have a natural childbirth in a hospital setting.) He never spoke with her that morning. He never got a newer ultrasound either prior or after the unsuccessful laparoscopy.

Post-facto, the guess was that she passed the IUD during her spotting, which is why the spotting resolved itself.

I think the surgeon assaulted her. I think what he did was unnecessary and incompetent. I think it was criminal.

We had a 6 month (or so) old kid, and instead of her having minimally invasive surgery, suddenly she was having a major recovery in which she could not pick up objects over 10 pounds for six weeks.

She had to recover. She had to take off work. I had to take off work.

She sued the guy of course, but it was hard, because tort reform in California meant that the maximum damages made the lawsuit uninteresting to 99% of divorce attorneys.

I never found out what happened, but if she got anything from the guy, she deserved it.

But instead of tort reform limiting damages, I'd be happier with a health court that might limit damages, but would also revoke licenses, or even refer cases to criminal court.

I haven't spoken to a doctor or lawyer about this, I'd really like to hear someone defend his actions as other than a criminal assault.

"The distinction about whether I would do it "personally" is a red herring. Government is the mechanism we use to enforce social norms and obligations."

LOL, yes of course. Because it is simply such a done deal that we all accept that there government mechanism. Apparently the naive EMG doesn't realize the lengths some people will go to avoid subsidizing her entitled derriere.

Look, I don't care about you or your family or your problems at all. If the choice was paying one cent in taxes that was to go to you or throwing it down a sewer, the sewer wins.

While I don't necessarily agree with your thoughts on entitlement programs. I do thank you for being a member of the medical community and actually coming out and SAYING SOMETHING. I found your site through Oprah's website btw!

Char said "The reason why health care is so expensive is because of government programs such as Medicare and Medicaid and laws which drive the cost up (such as the law that hospitals have to treat everyone free of charge in the emergency room)."

This is partially true - but, honestly if you ask any human resource manager why their insurance costs are going up - you will find it's because of all the prescription drugs that all their employees are taking....that's a HUGE reason the cost of care is through the roof.

I work in the medical field - and my biggest frustration is the funding of "meaningful use". The funding for doctors and hospitals to use electronic health records is coming from medicare and medicaid (when it should be used to treat medical conditions of patients). I know first hand that the reimbursement to physicians is already way too low - so, I can support them getting compensataed via "meaningful use" - but, it's still ridiculous. I don't think the average person realizes where this funding is coming from....rather than paying medical professionals to use EHR - just pay them what their services are worth.

Here's a little information on this program:

The Medicare EHR Incentive Program will provide incentive payments to eligible professionals, eligible hospitals, and CAHs that demonstrate meaningful use of certified EHR technology.•Eligible professionals can receive up to $44,000 over five years under the Medicare EHR Incentive Program. There's an additional incentive for eligible professionals who provide services in a Health Professional Shortage Area (HSPA).•Incentive payments for eligible hospitals and CAHs may begin as early as 2011 and are based on a number of factors, beginning with a $2 million base payment.

The Medicaid EHR Incentive Program•Eligible professionals can receive up to $63,750 over the six years that they choose to participate in the program.•Eligible hospital incentive payments may begin as early as 2011, depending on when the state begins its program. The last year a Medicaid eligible hospital may begin the program is 2016. Hospital payments are based on a number of factors, beginning with a $2 million base payment.

Thank you, Dr. Wes, for continuing to educate patients on upcoming issues regarding health care! I don't think people realize how quickly their health can spiral out of control - there are consequences to the life choices we make.

I am appalled at the people who want to push onward with obamacare...saying everyone will now be covered...I have NEVER heard of someone being denied ANY treatment from ANY doctor or hospital. I know for a fact that the young black teenager who had suffered a gunshot wound from a drive by shooting and was brought into the er while I was there with my child who was having difficulty breathing wasn't turned away..I know he had no insurance and yet he was whisked straight away to surgery ahead of my child as he rightly should have been. There has been no injustice of the doctors or hospitals failing to perform. Does healthcare cost a lot? Yes! We already pay for those who are uninsured by higher prices and high insurance premiums. However, I enjoy paying!! Let me pay more, as long as I can receive the care I or my family needs, no matter our age, weight, or bad habits!!

I am appalled at the people who want to push onward with obamacare...saying everyone will now be covered...I have NEVER heard of someone being denied ANY treatment from ANY doctor or hospital. I know for a fact that the young black teenager who had suffered a gunshot wound from a drive by shooting and was brought into the er while I was there with my child who was having difficulty breathing wasn't turned away..I know he had no insurance and yet he was whisked straight away to surgery ahead of my child as he rightly should have been. There has been no injustice of the doctors or hospitals failing to perform. Does healthcare cost a lot? Yes! We already pay for those who are uninsured by higher prices and high insurance premiums. However, I enjoy paying!! Let me pay more, as long as I can receive the care I or my family needs, no matter our age, weight, or bad habits!!

In the back of my ambulance you know how much I care about their ability to pay or how much Mcdonalds they are to have their massive MI?

Not on freaking bit.

Sick = Help. Plain and simple.

I love medicine, I love my patients. They deserve respect compassion and empathy. I may not be able to change their lifestyle, but I can alleviate their pain, give them a chance, hold their hand, or save their life. I'll make a tiny difference one way or the other.

And I'll do it all for 10 bucks an hour despite my Bachelor's Degree.

I learn everything I can, not for status, not for money, but to do better for my patients. Sometimes resources are finite, sometimes we don't get every tool, but we still make a freaking difference.

It saddens me that the physicians that take over care are greedy, cynical a-holes who think it ethical to whine about reimbursement and pay.

People trust you - with their lives, their children's lives, their parent's lives.

They believe you are caring, knowledgable, empathetic people.

Too bad you forgot how LUCKY you are that you get make a difference in another human beings life.

TJ, and others less explicitly, are basically saying "let 'em eat cake, their lives are worth less than tossing a coin into the sewer." Do you long for a "libertarian" utopia, where the rich are unencumbered by noblesse oblige, and the lives of those you consider beneath you, parasites, are worth less than tossing a coin into the sewer? One would think that knowing one's history would be reason enough to care a little bit about the welfare of others, even if only to save your own skins.

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About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.